Synopsis While returning to Westport, Nova Scotia, in good weather and sea conditions on the second day of the 1993 lobster fishing season, the STUMP JUMPER ran aground on a rock ledge in the approach channel, resulting in the total loss of the vessel. Three of the four crew members were rescued by two other fishing vessels but the operator lost his life. The Board determined that the STUMP JUMPER grounded due to a navigational error while making an approach to the harbour, in part because the operator's performance was impaired by his poor health and work-induced fatigue. The fact that the operator, who could not swim, was not wearing any form of flotation device contributed to his loss. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The STUMP JUMPER was of wooden, open construction, built to the Cape Island design and rigged for lobster fishing (see Appendix A). The hull had been sheathed with glass-reinforced plastic (GRP) and was subdivided by three transverse bulkheads below the main deck. The wheel-house/navigation position was in the forward part of the vessel, and the after open deck work area was fitted with a bulwark some 80 cm high. 1.2 History of the Voyage The vessel departed from Westport, Nova Scotia, at 05303, 30 November 1993, on a routine day trip. The crew of four, comprising the owner/operator and three deck-hands, fished at various lobster fishing grounds; all within a five-mile radius from the harbour (see Appendix B). Fishing was completed at 1730 and the catch of some 1,360 kg of live lobsters was stowed in containers on deck. The vessel then headed toward the entrance to Grand Passage to return to harbour; her estimated time of arrival was 1900. When entering harbour, the operator had the hands-on control of the vessel. While navigating from the wheel-house, he was also engaged in steering, keeping a look-out and controlling the speed. The other three crew members did not participate in the navigation and were relaxing. One was in the accommodation, another in the wheel-house and the other on the afterdeck. After passing between buoy HA2 and Dartmouth Point and while proceeding at an estimated speed of 10 knots in darkness but in good visibility, the vessel unexpectedly grounded on Dartmouth Point Ledge at 1815 (see Appendix B). The vessel rode up on to the edge of the ledge, exposing her port side to a south-westerly swell which caused her to work heavily against the rocky ledge. The crew members, who were jolted and startled, gathered in the wheel-house to assess the situation. The operator was heard to say words to the effect What happened? How did we get here? There were no injuries. No one could determine the reason for the grounding. They confirmed that the vessel had run aground on Dartmouth Point Ledge and realized that the vessel was in danger of either capsizing or breaking up by the actions of the waves. Messages requesting assistance were transmitted on the very high frequency radiotelephone (VHF R/T) by the STUMP JUMPER and were responded to by other fishing vessels and primary Search and Rescue (SAR) units. Three of the four crew members were rescued. 1.3 Injuries to Persons The cause of death of the operator, as established by the attending physician, was drowning in seawater. No significant injuries were noted. 1.4 Damage 1.4.1 Damage to the Vessel The STUMP JUMPER sustained extensive hull damage and some equipment was salvaged before she eventually broke up. 1.4.2 Environmental Damage The remaining diesel fuel oil escaped from the vessel but was quickly dissipated by wind and wave action. Pollution was considered to be negligible. 1.4.3 Other Damage Another fishing vessel sustained minor hull damage during rescue operations. 1.5 Certification 1.5.1 Vessel Being under 15 gross registered tons (GRT), the STUMP JUMPER was not required to be inspected by the Ship Safety Branch (SSB) of the Canadian Coast Guard (CCG), and she had not been so inspected. Insurance records indicated that the STUMP JUMPER was well maintained and the overall condition was satisfactory. 1.5.2 Personnel Certification and History None of the crew members were required to be certificated to operate a vessel of this size and type. However, the crew members who used the radio were required to be appropriately certificated. 1.5.2.1 Owner/Operator The owner/operator had some 40 years' fishing experience in the same area on similar small open fishing vessels and had operated the STUMP JUMPER since 1973. He did not hold formal marine qualifications to operate the vessel or the VHF R/T. Reportedly, he could not swim. 1.5.2.2 Deck-hands Two of the three deck-hands had considerable lobster fishing experience and had spent some 16 and 10 years respectively fishing with the operator on the STUMP JUMPER. The third deck- hand was on his first fishing trip. Two of the three deck-hands could not swim. One deck-hand held a Fishing Master, Class IV, Certificate of Competency obtained in 1982, a requisite part of which is a Marine Emergency Duties Certificate. He also held a radio operator's licence. 1.5.3 Crew Health and Medical Examination After the grounding, the operator was lying on the open deck, unable to help himself. Reportedly, he was alive but was unable to verbally respond to questions before he was swept overboard. There is no regulatory requirement for fishermen to undergo medical examination to be eligible for employment aboard vessels. In this instance, the operator was obese and the medical records indicated that he was under treatment for diabetes (non-insulin dependent). His blood sugar content was at times elevated because he did not always take his medication. It is not known whether the operator had taken his medication on the day of the occurrence nor the last time he had taken it. (See Sections 1.6.4 and 2.3 for further discussion of the operator's condition.) 1.6 Factors Affecting Crew Performance 1.6.1 The Lobster Season and Fishing Operations In south-west Nova Scotia, the season starts at the end of November each year and runs through May of the following year. In the Maritimes, lobsters are caught using traps (pots) set on the sea-bed either individually or in groups of up to eight on a line. The size and design of the traps differ somewhat but they often weigh in excess of 40 kg. The traps are set on the opening (first) day of a season. Commencing the following day, the traps are hauled by powered winches, emptied, re-baited and lowered again to the sea-bed. The catch is transported live to harbour where, in this case, it was to be retained in seawater-permeated wooden crates, referred to as cars, for later sale. 1.6.2 Work Patterns The operator had the hands-on control of the vessel while entering and leaving port. He also navigated to the positions where the traps were set and manoeuvred between them. The other three crew members attended to the catch and, occasionally, one relieved the operator while he worked with the catch. 1.6.3 Eating and Resting Patterns There were no set eating and resting patterns. On board, there was cold-packed food and hot coffee, taken during the short periods between attending to the traps and when travelling to and from the harbour. 1.6.4 Work Environment and Fatigue Fatigue is generally related to the number of hours worked, the inability to obtain regular and uninterrupted sleep, and exposure to stressful and high workload situations (Pollard, Sussman, and Stearns, 1990). Further, the marine work environment and conditions (e.g., noise, vibration, and temperature extremes) are known to be potentially stressful (Pollard et al., 1990). Further, researchers at the Defence and Civil Institute of Environmental Medicine (DCIEM) found that a 30 per cent decrement in performance of cognitive tasks could be expected after 18 hours of wakefulness (Angus, Pigeau, and Heslegrave, 1988). Performance is further affected by medical fitness, more so in persons suffering from some specific symptom such as a diabetic condition. Some of the effects of diabetes are dizziness, such as mental confusion, and partial blackout. In this instance, the crew had arisen at about 0430, 30 November, commenced fishing at about 0630 and the vessel grounded at 1815. Some of the 375 traps which had been set the previous day were hauled, re-baited and re-set in some 11 hours by the operator. The operator was under treatment for a diabetic condition. 1.7 Meteorological Information Weather forecasts issued by Environment Canada at 0530 on 30 November 1993 indicated north- west winds of 10 to 15 knots, increasing to 15 to 20 knots that evening, with continuing good visibility. The weather conditions at the time of the grounding were: winds north-west at 20 to 30 knots, light-to-moderate seas in the lee of the land, good visibility and a heavy south-westerly swell due to recent storms. 1.7.1 Tidal Information Low water at nearby Westport was predicted to occur at approximately 1800 on 30 November and low water slack some 20 minutes earlier. The tidal direction and rate in the area are subject to variations depending upon the wind direction, duration and speed. The grounding occurred approximately one mile to the south-west of Westport, and local knowledge indicates that the flood tide was just beginning to build. 1.8 Navigational Aids The navigation equipment aboard the vessel included a magnetic compass, depth sounder, Loran C, radar and VHF R/T. All this equipment was in use and reportedly operating satisfactorily. The fixed navigational aids in the area were in the positions as depicted on a local chart. The light on Peters Island and those at the extremities of the three wharves at Westport and Freeport were clearly visible. Following the grounding, the position of light and bell-buoy HA2 was checked; the buoy was found to be 5.5 cables south of its charted position. The buoy, which exhibited a red flashing light, was required to be left on the starboard side of the vessel. Reportedly, as in this instance, some of the local lobster vessel operators do not use this buoy as intended but prefer to pass between the buoy and Dartmouth Point when navigating the entrance to the channel. The distance between the 10 m contour off Dartmouth Point Ledge and the charted position of buoy HA2 is approximately two cables. 1.8.1 Navigation by the STUMP JUMPER It is not common practice for fishing vessels of this type and size to prepare a detailed navigation plan when entering and leaving harbour or to use a chart. Instead, navigation is carried out using skill and local knowledge. The STUMP JUMPER was being navigated in this manner with the intention of proceeding first to Westport to refuel, then to cross Grand Passage to Freeport to discharge the catch at the cars. It was the first time the operator had sold his catch to a buyer (who owned the cars). Shortly before the grounding, VHF R/T calls advised the operator that the buyer was waiting to receive the catch at the cars. Consequently, course was altered toward Freeport. The cars were located on the east side of the channel; Westport is on the west side. 1.9 Radio Communications 1.9.1 Very High Frequency Radiotelephone Frequencies The STUMP JUMPER, the CCGS WESTPORT, the Rescue Co-ordination Centre (RCC) Halifax and the Department of National Defence (DND) SAR helicopter were all equipped with VHF R/Ts capable of operating on various frequencies including channel 16 and channel 6. Coast Guard Radio Station (CGRS) Yarmouth has voice-recording capability for broadcasts made on channel 16 but not for channel 6. All stations, with the exception of RCC Halifax, were within VHF operating range. Communications between the RCC and the CGRS were maintained by mobile and land-line telephones. Lobster vessels in the area use channel 6 as a working frequency to communicate with each other. 1.9.2 Coast Guard Radio Station Distress Communication Procedure The CGRS monitors channel 16, the international calling and distress frequency. In the event of a MAYDAY call, the distressed traffic is advised to stay and communicate on channel 16. No other traffic is allowed to interfere with the distress communication or to broadcast on the distress frequency. After the distress traffic has been well established and following CGRS broadcast, normal transmission/working is allowed to be resumed. 1.9.3 Distress Communication Shortly after the grounding, the first call for assistance was made by the operator of the STUMP JUMPER on VHF R/T channel 11 and was not received by any station. At 1817, a subsequent call was made to the WESTPORT by one of the deck-hands on channel 16. It read: Coast Guard WESTPORT, are you on this one? This message was not prefixed by the spoken word Mayday. Nevertheless, CGRS Yarmouth, knowing that the WESTPORT crew members were off duty, intercepted the message seeking distress-related information and enquired if assistance was required. Before full information could be obtained, the VHF R/T on the STUMP JUMPER was switched from channel 16 to channel 6 to inform other vessels in the area and solicit assistance. Several fishing vessels responded. Meanwhile, RCC Halifax was alerted by CGRS Yarmouth and the WESTPORT was tasked. Under instructions from CGRS Yarmouth, the WESTPORT advised the lobster vessels to switch to and monitor channel 16. Instead, the lobster vessels preferred to stay on channel 6. Only one other vessel briefly contacted CGRS Yarmouth on channel 16 but was unable to provide details on the occurrence. Communication between CGRS Yarmouth and the STUMP JUMPER was as follows: STUMP JUMPERHere off Westport, and we got to get something over here quick we're going to roll over. CGRS What's the name of your vessel and could I get your position please, over. STUMP JUMPERThis is the STUMP JUMPER and we're right here ... in the mouth of the passage off Peters Island. We're aground on the Ledge, she's going to roll ... over if they don't get here quick. Just the mouth of Westport Passage. CGRS Roger sir roger on that, how many people on board, over. STUMP JUMPERThere's four people on board, we ain't got time to talk, we got to do something. The series of calls ended at 1818 (approximately 60 seconds after initiation). 1.10 Search and Rescue Operations 1.10.1 Fishing Vessel Rescue Efforts Before the arrival of other vessels on scene, one of the deck-hands tied a lobster trap buoy to his arm and allowed himself to be carried over the side by one of the waves. The first two fishing vessels arrived on scene some five minutes after the grounding and were quickly followed by several others. All were equipped with searchlights and they illuminated the scene while evaluating rescue attempts. The STUMP JUMPER was observed moving on the rocks and it was determined that a close approach would be dangerous. Three persons were seen on deck; two were alert, standing up, and holding on to parts of the vessel, and the other (the operator) was lying on the deck, unable to help himself. Shortly afterward, the operator was swept over the side but was hauled back on board by the two deck-hands, only to be swept overboard again and lost to view. Meanwhile, the crew of one of the rescue vessels sighted the deck-hand in the water and rescued him. After another 20 minutes or so, the STUMP JUMPER swivelled on the ledge and her stern swung into deeper water. One of the fishing vessels took the opportunity to move alongside the STUMP JUMPER and rescue the remaining two crew members. The operator was pulled from the sea approximately one hour later by a fishing vessel. Attempts at resuscitation were unsuccessful and the operator was transported ashore where he was pronounced dead. 1.10.2 WESTPORT Rescue Efforts The WESTPORT is an all-steel, twin-screw vessel designed for inshore rescue work. The 13.4 m vessel has a draught of 1.09 m and a crew of three comprising a coxswain and two deck- hands. The WESTPORT is equipped with a rigid-hull inflatable raft primarily intended to serve as a lifeboat. During SAR operations, a minimum of two persons are necessary to man the raft; it was not used in this instance. Following the initial 1817 transmission from the STUMP JUMPER, RCC tasked the WESTPORT at 1818 by alerting the off-duty crew members through their pagers. The WESTPORT departed from the berth at 1823, five minutes later, arriving on scene at about 1829. After assessing the situation, the WESTPORT advised RCC at 1836 that helicopter services were immediately required. Many fishing vessels were in the immediate area attempting rescue operations. Consequently, there was limited space for manoeuvring and this precluded immediate safe/direct participation of the WESTPORT. Before the WESTPORT could actively participate in the rescue effort, her two deck-hands, who were outside the wheel-house, kept a look-out for survivors, and the coxswain illuminated the area with a searchlight while relaying information to the RCC. After the three survivors had been rescued, the WESTPORT was able to join in the search for the operator, maintaining communication with all participants. 1.10.3 Helicopter Rescue Efforts The helicopter crew members were off duty when they were tasked at 1842. The helicopter was airborne at 1924, arriving on scene at 1949. There was still some uncertainty as to the whereabouts of the missing person and, after assessment of the situation, a SAR technician was lowered to the STUMP JUMPER by wire hoist. During a search of the vessel and the immediate area, two or three lifejackets were seen floating in the flooded cuddy but there was no sign of the operator. The SAR technician was later informed that the operator had been pulled from the water and landed ashore, as were the survivors. The SAR technicians were then transported and landed ashore to render medical assistance. While they were attempting to resuscitate the operator, the local physician arrived and pronounced him dead. 1.10.4 Deployment and Response of Search and Rescue Resources The primary marine SAR unit WESTPORT is stationed at the port of Westport. The vessel is on continuous stand-by from 0800 to 1600 and on 30-minute stand-by thereafter. After 1600, the crew is alerted through a paging system. During the period of high fishing activity, when the need for SAR resources is greatest, air SAR resources are strategically positioned to minimize transit time. In accordance with established procedures, the helicopter was required to be on 30-minute stand-by from 0700 to 1600 when not engaged in SAR patrol and on 2-hour stand-by after 1600. 1.10.5 Perceived Inadequacy of Search and Rescue Services During the investigation, local residents raised the following concerns regarding the efficiency of CCGS WESTPORT, CGRS Yarmouth and the DND helicopter: The CGRS sought too many irrelevant details, such as the colour of the vessel, which wasted precious time given the urgency of the situation. The WESTPORT played a passive role in the rescue effort, letting the fishing vessels play a more active role. The WESTPORT did not light the area with flares. The WESTPORT did not launch her rigid-hull inflatable rescue craft. The helicopter arrived on scene too late and should have been available immediately. 1.11 Life-saving Equipment The life-saving equipment aboard the STUMP JUMPER comprised one inflatable liferaft, stowed on the wheel-house top; four approved lifejackets, stowed in the cuddy; and one approved lifebuoy with line, stowed on the side of the wheel-house. Following the grounding, the flooding of the vessel and the failed lighting in the cuddy precluded access to the lifejackets, and the violent movement of the vessel on the rocks precluded the deployment of the liferaft and the lifebuoy. None of the crew members was wearing a personal flotation device (PFD). There is no regulatory requirement for vessels of this size and type to carry anti-exposure worksuits or for their crews to wear them. The worksuits are designed to provide the wearer with acceptable flotation and thermal protection without hindering his ability to perform normal work duties. Some fishermen consider the suits too warm to be worn during fishing operations and are consequently reluctant to accept them. 1.11.1 Use of Life-saving Equipment During Fishing Operations Lifejackets and immersion suits are primarily designed to be used in emergency situations that may culminate in abandonment of the vessel. While both are designed to keep a person in the water afloat in a face-up position, the immersion suit is also intended to provide thermal protection. Both are cumbersome to use and interfere with normal performance in everyday work situations. To address this shortfall, the CCG has developed standards for anti-exposure worksuits for fishermen. Several different brands are now available on the market. A survey conducted by the CCG in 1993 found that 62 per cent of the respondents believed that the worksuit was too warm to wear during the summer. However, 90 per cent of the respondents indicated that they would wear the worksuit during cold or poor weather conditions.